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Consent Form Requirements <br />I le,,ilth and Sarety Code <br />Client is at least 18 years of age - 119' )02 (a) <br />El <br />Ntr nts/Guard'an signature ;D -e of minor receiving body piercing -- 119302 (b) - <br />Signature ()I-cl,elit a-1-ce'lig they have, read and completed the consent roi-ni - 1193)03 (a) <br />1 agreeing <br />Description of procedure --- 1193103 (a) I <br />-Description of what the client s1,0111cl expect ri.)1lowhia the procedure - 199303 (a) 2 <br />Statement regarding permanent nature of procedure - 119303 (a) 3 <br />LL --I Post procedure instructions - 119303 (a) 4 <br />a).-ififormation of proper care for procedure site <br />­gpi-estrictions on physical activities <br />c sions and symptoms of infection <br />--5'�-Ijjaications when to seek medical care <br />Medical Questionnaire <br />H&SC 119303 (b) <br />Client status regarding pregnancy - 119303 (b) I <br />k+----ijistoFy of herpes infection at the procedure site - 119303 (b) 2 <br />-Er" History of diabetes - 119303 (b) 2 <br />History of allergic reactions to latex -119303 ) 03 (b) 2 <br />1.3 <br />History of allergic reactions to antibiotics - 119303 (b) 2 <br />History of hemophilia or other bleeding disorders - 119303 (b) 2 <br />-LI---T-Iistory of cardiac valve disease 11930' ) (b) 2 <br />Current medications- 119303 (b) 3 <br />Requirements for antibiotics prior to surgery or dental procedures - 119303 (b) 3 ) <br />--fT— Other risk factors for blood borne pathogens - 119303 (b) 4 <br />